Chapter 4

Nurses are often placed in situations where they are expected to be agents for patients, physicians, and
the organization simultaneously, all of which may have conflicting needs, wants, and goals.
The nurse-manager has a different ethical responsibility than the clinical nurse and does not have as
clearly defined a foundation to use as a base for ethical reasoning.
Nurses often find themselves viewed simultaneously as advocates for physicians, patients, and the
organizationall of whose needs and goals may be dissimilar.
Moral indifference occurs when an individual questions why morality in practice is even necessary.
Moral uncertainty or moral conflict occurs when an individual is unsure which moral principles or values
apply and may even include uncertainty as to what the moral problem is.
Moral distress occurs when the individual knows the right thing to do but organizational constraints
make it difficult to take the right course of action.
Moral distress in health care is a growing concern and that it impacts satisfaction, the recruitment and
retention of health-care providers, as well as the delivery of safe and competent quality patient care.
Davis, Schrader, and Belcheir (2012) surveyed 1144 Idaho nurses. Approximately 35% of the nurses
reported experiencing moral distress in the workplace at least once a month and 27.7% reported leaving
a job due to moral distress.
Nurses with strong religious beliefs had significantly higher moral distress than those who identified the
nurses Code of Ethics, family values, or work/life experiences as the compass for their ethical beliefs.
The researchers concluded that because religion and spiritual beliefs may pose additional moral distress
for nurses in dealing with ethical dilemmas
Moral outrage- example of six new mexico nurses who blew the whistle on a doctor.
The most difficult of all moral issues is moral dilemma, which may be described as being forced to
choose between two or more undesirable alternatives.
For example, a nurse might experience a moral dilemma if he or she was required to provide care or
treatments, which were in conflict with his or her own religious beliefs. In this case, the nurse would
likely experience an intrapersonal moral conflict about whether his or her values, needs, and wants can
or should supersede those of the patient.
*Individual values, beliefs, and personal philosophy play a major role in the moral or ethical decision
making that is part of the daily routine of all managers. Self-awareness, then, is a vital leadership role in
ethical decision making, just as it is in so many other aspects of management.
Critical thinking occurs when managers are able to engage in an orderly process of ethical problem
solving to determine the rightness or wrongness of courses of action.
Ethical frameworks guide individuals in solving ethical dilemmas. These frameworks do not solve the
ethical problem but assist the manager in clarifying personal values and beliefs.

4 ethical frameworks are:

1.
2.
3.
4.

Utilitarian
Rights Based
Duty Based
Intuitionist

A. Utilitarian provide greatest good for greatest number of people

3 Examples from book:
1. A manager using a utilitarian approach might decide to use travel budget money to
send many staff to local workshops rather than to fund one or two people to attend a
national conference.
2. An insurance program that meets the needs of many but refuses coverage for
expensive organ transplants.
3. Organization uses utilitarianism to justify lying to employee applicants because their
hiring would result in good for many employees by keeping several units in the hospital
open
B. Duty-based reasoning is an ethical framework stating that some decisions must be made because
there is a duty to do something or to refrain from doing something.
Example from book: the supervisor feels a duty to hire the most qualified person for the job, even
if the personal cost is high.
C. Rights-based reasoning is based on the belief that some things are a persons just due (i.e., each
individual has basic claims, or entitlements, with which there should be no interference). Rights are
different from needs, wants, or desires.
Examples in book:
1. The supervisor in Learning believes that both applicants have the right to fair and impartial
consideration of their application.
2. Sam believes that all people have the right to truth and, in fact, that he has the duty to be
truthful.
D. The intuitionist framework allows the decision maker to review each ethical problem or issue on a
case-by-case basis, comparing the relative weights of goals, duties, and rights. This weighting is
determined primarily by intuitionwhat the decision maker believes is right for that particular
situation.
Recently, some ethical theorists have begun questioning the appropriateness of intuitionism as an
ethical decision-making framework because of the potential for subjectivity and bias.
All of the cases solved in this chapter involve some degree of decision making by intuition.
Ethical relativism suggests that individuals make decisions based only on what seems right or
reasonable according to their value system or culture.

Ethical universalism holds that ethical principles are universal and constant and that ethical decision
making should not vary as a result of individual circumstances or cultural differences.

The most fundamental universal principle is respect for people.

The 9 ethical principles stem from this basic principle
1. Autonomy: freedom of choice
Example: The use of progressive discipline recognizes the autonomy of the employee. The
employee, in essence, has the choice to meet organizational expectations or to be disciplined further. If
the employees continued behavior warrants termination, the principle of autonomy says that the
employee has made the choice to be terminated by virtue of his or her actions, not by that of the
manager.
2. Beneficence: the actions one takes should be done in an effort to promote good.
Example: if a manager uses this ethical principle in planning performance appraisals, he or she is
much more likely to view the performance appraisal as a means of promoting employee growth
3. Non-maleficence, which is associated with beneficence, says that if one cannot do good, then one
should at least do no harm.
4. Paternalism: one person assumes the authority to make a decision for another. Because paternalism
limits freedom of choice, most ethical theorists believe that paternalism is justified only to prevent a
person from coming to harm.
Example: Unfortunately, some managers use the principle of paternalism in subordinates career
planning. In doing so, managers assume that they have greater knowledge of what an
employees short- and long-term goals should be than the employee does.
5. Utility: what is best for the common good outweighs what is best for the individual.
Utility justifies paternalism as a means of restricting individual freedom. Managers who use the
principle of utility need to be careful not to become so focused on desired group outcomes that they
become less humanistic.
6. Justice (or Treating People Fairly): equals should be treated equally and that unequals should be
treated according to their differences. This principle is frequently applied when there are scarcities or
competition for resources or benefits.
Example: The manager who uses the principle of justice will work to see that pay raises reflect
performance and not just time of service.
7. Veracity (Truth Telling): principle is used to explain how people feel about the need for truth telling or
the acceptability of deception.
Example: A manager who believes that deception is morally acceptable if it is done with the
objective of beneficence may tell all rejected job applicants that they were highly considered
whether they had been or not.
8. Fidelity (Keeping Promises): Fidelity refers to the moral obligation that individuals should be faithful to
their commitments and promises.

Although nurses have multiple fidelity duties (patient, physician, organization, profession, and
self) that at times may be in conflict, the ANA Code of Ethics is clear that the nurses primary
commitment is to the patient (ANA, 2001).
9. Confidentiality (Respecting Privileged Information)
However, as in deception, there are times when the presumption against disclosing information must
be overridden. Example: health-care managers are required by law to report certain cases, such as
drug abuse in employees, elder abuse, and child abuse.
ANA CODE OF ETHICS FOR NURSES
This code outlines the important general values, duties, and responsibilities that flow from the specific
role of being a nurse. While not legally binding, the code functions as a guide to the highest ethical
practice standards for nurses and as an aid for moral thinking.

Another document that may be helpful specifically to the nurse-manager in creating and maintaining an
ethical work environment is The Scope and Standards of Practice of Nursing Administration Practice
published by the ANA. These standards, revised in 2009, specifically delineate professional standards in
management ethics. (see box on next page.)

Ethical Problem Solving:

The best possible decisions stem from structured problem solving, adequate data collection, and
examination of multiple alternativeseven if outcomes are poor.
If a structured approach to problem solving is used, data gathering is adequate, and multiple
alternatives are analyzed, even with a poor outcome, the nurse should accept that the best possible
decision was made at that time with the information and resources available.
Theorypracticeethics gap examples:
1. Noncompliance exists in hand hygiene among practitioners despite ongoing infection
prevention education and training, etc. Thus, despite nurses having knowledge of best practices
based on current research, they continue to fail to achieve the required and desired compliance
in hand hygiene.
2. While nurses recognize that checklists can reduce episodes of patient harm by ensuring that
procedures are being carried out appropriately, that some providers will indicate that an
intervention has been undertaken when it has not. This occurs because of the mantra If it
wasnt documented, it wasnt done and an increasing emphasis and reliance on
documentation that demands that all boxes must be ticked to ensure complete care has
been provided. Kearney and Penque suggest then that checklists present a context for ethical
decision making in that when providers do not take ethics into account, checklists could
actually perpetuate rather than prevent unsafe practices or errors.

THAT IS INTERESTING!

Crisham (1985) developed a model for ethical decision making incorporating the nursing process and
principles of biomedical ethics. This model is especially useful in clarifying ethical problems that result
from conflicting obligations. This model is represented by the mnemonic MORAL

MORAL=

Massage the dilemma: Collect data about the ethical problem and who should be involved in the
decision-making process.

Outline options: Identify alternatives, and analyze the causes and consequences of each.
Review criteria and resolve: Weigh the options against the values of those involved in the decision. This
may be done through a weighting or grid.

Affirm position and act: Develop the implementation strategy.

Look back: Evaluate the decision making.
The concerns about ethical conduct in American institutions are documented by many news articles in
the national press. Many individuals believe that organizational and institutional ethical failure has
become the norm.
Nurse-managers, then, have a responsibility to create a climate in their organizations in which ethical
behavior is not only the expectation but the norm.
4 strategies leader-managers can use to promote ethical behavior as the norm:
1. Separate legal and ethical issues
2. Collaborate through ethics committees
3. Use Institutional Review Boards appropriately
4. Foster an ethical work environment - perhaps the most important thing a leader-manager
can do to foster an ethical work environment is to role model ethical behavior.

CHAPTER 5!!!!!!!!!!!!!!!!!!!!

PURPOSE OF LAW AND LEGISLATION

The primary purpose is to protect the patient and the nurse.
Laws and Legislation define the scope of acceptable practice and protect the individual rights.
TYPES OF LAW AND COURTS
The Nurse Practice Act is not found in criminal or civil cares. ONLY found in administrative
cases.
1.Criminal Beyond a reasonable doubt is what is needed for a guilty verdict. Incarceration,
probation, and fines.
2. Civil Based on a preponderance of the evidence. Monetary damages
3. Administrative -- THIS IS THE ONE THAT WE CARE ABOUT Clear and convincing standard.
Suspension or lose of licensure.
LEGAL DOCTRINES GUIDING COURTS IN DECISION MAKING
Stare decisis (let the decision stand): uses precedents as a decision-making guide
*Precedent is often used as a guide for legal decision making*
Res judicata (a thing or matter settled by judgment): Applies when a competent court has
decided a legal dispute and when no further appeals are possible (Normal court how it should
go, atleast)
Respondeat superior (The master is responsible for the acts of his servants): An employer
should be held responsible for the conduct of the employees whose actions he or she has a
right to direct or control.
IMPORTANT IN NURSE PRACTICE ACTS
Nurse Practice Acts authorizes that:
1. Only RNs can practice professional nursing
2. Assignments should be made in line with the nursing personnels educational
preparation, experience, and knowledge
3. A nurse must supervise care provided by nursing personnel for which the nurse is
responsible for.
4. Sterile or invasive procedures should be assigned or supervised by an RN or LPN who
has been checked off on the procedure

ELEMENTS OF MALPRACTICE
Negligence- The omission to do something that a reasonable person would do
Malpractice- The failure of a person with professional training to act in a reasonable and
prudent manner ALSO CALLED PROFESSIONAL NEGLIGENCE.

TORTS
Definition: A tort is a wrongful act involving injury or damage
Two classes: Intentional and Unintentional
Unintentional
a.) Ordinary negligence- performing an act that a reasonable & prudent person would not
perform
b.) Professional negligence- professional misconduct or unreasonable lack of skills in
carrying out professional duties
Intentional
a.) Assault- Mental or physical threat
b.) Battery- Harmful touch with or without intent to do harm
c.) Invasion of privacy

d.) Fraud- presenting false credentials for nursing school, obtaining a license, obtaining
employment.
COMMON CAUSES OF PROFESSIONAL NURSING LICENSE SUSPENSION OR REVOCATION
Professional negligence, practicing without a license, obtaining a nursing license by fraud or
allowing others to use your license, felony conviction related to duties of an RN, participating in
criminal abortions, not reporting substandard medical or nursing care, providing patient care
under the influence of drugs or alcohol, giving narcotic drugs without an order, falsely holding
oneself as a nurse practitioner.
EXAMPLES OF MALPRACTICE
Forgetting to give medication, giving the wrong medication, performing incompetent
assessments, failing to act on warning signs of shock, MI, or other critical warning signs,
Knowingly assigning care to an incapable caregiver, not supervising care, not being persistent in
notifying healthcare providers when need be.
BEING SUED FOR MALPRACTICE
Just following physician orders is NOT a defense for malpractice. Nurses have an independent
responsibility to take appropriate steps to safeguard patients.
HOSPITALIZED PSYCHIATRIC PATIENTS HAVE THE RIGHT TO:
Wear their own clothes, have a small amount of money, have an individual storage space, see
visitors daily, right to use the telephone and have private conversations, receive and send mail,
refuse shock therapy & lobotomy.
*Persons declared incompetent have legal rights of a minor and cannot vote, make contracts or
wills, drive a car, sue or be sued*
GUIDELINES FOR INFORMED CONSENT
The person giving consent must fully comprehend:
1.
2.
3.
4.
5.

The procedure being performed

The risks involved
The expected outcomes
Expected complications or side effects
Alternative treatments that are available

Consent may be given by:

1.
2.
3.
4.
5.
6.
7.
8.

A competent adult
A legal guardian
A POA
Verbal consent (Must be charted and witnessed by 2 persons, usually RNs
An emancipated or married minor
Mature minor (varies by state)
Parent of a minor
Court order

PATIENT SELF-DETERMINATION ACT (PSDA)

Organizations that receive federal funding (Medicare and Medicaid) have to provide education
to staff and patients on issues concerning treatment and end-of-life issues. (Includes the use of
ADs and POAs)
CHAPTER 6!!!!!!!!!!!!!!!!!!!
ADVOCACY
Definition: protecting and defending what one believes in for both self and others. Helping
others to grow and self-actualize.
Nurses may act as advocates by helping others make informed decisions, acting as an
intermediary in the environment, or by directly intervening on behalf of others.
The nurse values central to advocacy emphasize caring, autonomy, respect, and
empowerment.
Common areas requiring nurse-patient advocacy: End-of-life decisions, technological advances,
health-care reimbursement, access to health care, provider-patient conflicts, withholding of
information, insurance authorization, medical errors, patient information disclosure, patient
grievance, etc.
1998 PATIENTS BILL OF RIGHTS
3 key goals:
1.) Helps patients feel comfortable in the system
2.) Stresses strong patient-provider relationship
3.) Stresses key role patients play in staying healthy
2010 AFFORDABLE CARE ACT

Gives patients protection in dealing with insurance companies

LEGAL ADVANCES IN PATIENTS RIGHTS
1.) Patient Self-Determination Act ( deals with AD, Living Will, and POA)
2.) HIPPA (Privacy & Confidentially)
3.) American Recovery & Reinvestment Act (Expands HIPPA)
*Professional issues are ALWAYS ethical issues*
*If nursing is to advance as a profession, practitioners and leader-managers must broaden their
sociopolitical knowledge base to understand better the bureaucracies in which they live*
*Many nurses avoid media exposure because they believe they lack the expertise or because
they lack self-confidence*
*Speaking out as a whistle-blower is often honored more in theory than in fact*
CHAPTER 7!!!!!!!!!!!!!!!!!!!!!!!!!!!
PLANNING
Planning requires flexibility and energy. Planning also requires management skills such as data
gathering, forecasting, and transforming ideas into action.
Without planning, the management process FAILS, and organizational needs and objective
cannot be met.
BARRIERS TO INDENTIFYING LONG-TERM NEEDS IN PLANNING
1.
2.
3.
4.

Health-care reform
Rapidly changing technology
Increasing government regulation of health care
Scientific advances

*Most long-term planners find it difficult to even look 5 years in the future*
PROACTIVE PLANNING
Reactive planning- occurs AFTER a problem exists. This type of planning can lead to hasty
decisions and mistakes due to it being done in response to a crisis.
Inactivism- Seek the status quo. Spend their energy preventing change and maintaining
conformity. When changes do occur, they occur slowly.

Preactivism- utilize technology. Believe that the future is always preferable to the present.
Interactive or Proactive planning- Consider the past, present, and future equally important
when attempting to plan for the future. Adaptation is KEY due to the ever-changing
environment in health care.
STRATEGIC PLANNING
*This type of planning is also called long-term planning, as it deals with planning that involves a
long period of time (3-10 years)*
Strategic planning examines an organizations purpose, mission, philosophy, and goals.
All levels of employees participate
SWOT ANALYSIS
SWOT analysis is an effective tool that assists in strategic planning. It is commonly used.
S- Strengths are those internal attributes that help an organization to achieve its objectives
W- Weaknesses are those internal attributes that challenge an organization in achieving its
objectives
O- Opportunities are external conditions that promote achievement of organizations objectives.
T- Threats are external conditions that challenge or threaten the achievement of organizations
objectives.
STEPS:
1.
2.
3.
4.

Define the desired objective

Discover and list the SWOTs
Decide if objective can be achieved with those SWOTs
If they cannot, then start over with a new objective

MISSION STATEMENT
A brief statement identifying the reason that an organization exists. Typically only 3-4 sentences
long.
It is the highest priority in planning!!!
VISION STATEMENT

Describe the goals of the organization. One sentence long.

Chapter 8!!!!!!!!!!!!!!!!!!!